Referral – Keeping Families Together, LLC.

Keeping Families Together CCS Array Services Referral Form

Array Services Offered

Psychotherapy
Physical Health Monitoring (services provided by a Registered Nurse)
Individual/Family Psychoeducation
Individual Skills Development & Enhancement (ISDE), including bilingual staff
Peer Support
Substance Abuse Counseling
Employment-Related Skills Support Services
Anger Management

Please select the service(s) you are requesting:

Referral Information:

1. Service(s) Requested: *PsychotherapyPhysical Health MonitoringIndividual/Family PsychoeducationIndividual Skills Development (ISDE), including bilingual staffPeer SupportSubstance Abuse CounselingEmployment-Related Skills Support ServicesAnger Management

2. Date of Referral:

3. Participant Name:

4. Participant Gender Identity and Pronouns:

5. Participant Date of Birth:

6. Languages Spoken:(Please indicate if interpreter is needed)

7. How soon is the participant ready to begin services?

8. Parent/Guardian Name (if participant is a minor or under court-ordered guardianship):

9. Parent/Guardian Phone:

10. Parent/Guardian Email:

11. (Please include preferred method of contact):

12. Participant Desired Recovery Goals/Outcomes:

13. Frequency of Sessions:(Please list proposed number of sessions per week or month, and desired session length)

14. Availability:(Please list specific days and times the participant/family is available to meet)

15. Participant and Family Strengths:

16. Current Support Team Members:(Formal supports may include CCS providers, school staff, and medical professionals. Informal supports may include family, friends, and community members.)

17. Current and Past Mental Health Services:(Please include dates if known)

18. Current Diagnosis:

19. Prescribing Physician Information:

20. Current Medications:

Additional Helpful Information:(e.g., provider demographic preferences, cultural considerations, other relevant notes)

Submission Instructions

Please feel free to print a copy of your responses after you submit this form for your records.

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Keeping Families Together CCS Array Services Referral Form

Array Services Offered

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